Categorically Ill: My argument in favour of the diagnosis of mental illnesses

This is the viewpoint I gave at the debate on mental health diagnosis, “Categorically Ill”, at the Science Museum today.

It’s quite strange, quite sad I think, that after decades of anti-stigma campaigns, work by charities like Mind, so many confessions of mental illness and progressive government policies, that some people still doubt mental illness even exists. But I am very proud to defend it tonight. I don’t have the years of research experience that the other speakers have; all I have are years spent with patients and my own time as a patient. I hope that will be enough to convince you that I’m worth listening to tonight. I want to start by defining mental illness. Some people think that only your body can be ill, not your mind. But mind and body are two sides of the same coin- the mind is the product of the brain.

Mental illnesses are simply illnesses which involve the brain, but show themselves in a form we think of as “the mind”, like distressing thoughts, feelings and behaviours. Some are caused by brain diseases, like dementia. Some are caused by the outside world interacting with an initially fairly healthy brain, like alcohol addiction. Some are a mix of small brain changes and outside stress, like psychotic disorders.

But despite the fact that the brain is always involved in some way, we don’t just send all our patients to neurology – because we know that the mind deserves its own speciality – one that respects psychological and social factors, not just biological. Having this concept of mental illness is helpful for the same reasons having a concept of any kind of illness is helpful. It helps patients discover that they are not alone, that their suffering is not a private, unique torment, but that it has a name, and other people have been through it before. It allows them to learn about their difficulties and help themselves. Using the word illness, not just “problems”, ensures that society treats people with mental illnesses with the respect they deserve; not just lazy, peculiar, and malingering.

Calling someone ill, or giving someone a label, doesn’tremoves the unique meaning of their experiences, if you do it in the right way. If any of you have felt dehumanised by receiving a mental health diagnosis, it was the fault of the person who gave it to you, not the fault of the label. I listen to my patients, get to know them as individuals, hear their stories and their opinions on what they think might help – that’s why I went into psychiatry not neurology – but I also say to them, hey, your symptoms also fall into a group we see quite a lot – and there’s a whole load of research on that.

By recognising that certain symptoms often occur together, like flashbacks, being on edge and feeling numb and by giving this syndrome a name, in this instance PTSD, we can do research into causes, and treatments that might work. Sometimes we even find a cure. We learn from these patterns we see in people – we don’t have to start from square one with everyone that comes through the door.

So mental illness is a useful concept. But is it a valid one – are mental illnesses real? Of course they are. Some mental illness or disorders are quite plainly real. Dementia, addiction, severe autism and learning difficulties are all expressed through the mind, and therefore listed in those evil “psychiatric bibles” – but no one would argue that they didn’t exist.

But as soon as something is found to have a solid cause in the brain, it tends to get called “neurology”, so the heat can be kept focussed on psychiatry, on disorders for which a biological focus is less clear cut.

Some say, well, you’ve had years to find a simple cause or test for these disorders, things like depression, and you haven’t done it. So depression can’t be a real illness! But medicine doesn’t work like that. We don’t suddenly decide that the symptoms don’t add up to an illness just because we haven’t found a cause or a test yet – because the symptoms are still there. We don’t even have a good idea what causes migraines yet, we certainly don’t have a test, but no one will be telling people with headaches that sorry, no clear cause yet and no test, so no illness. So we won’t stop calling things like OCD and bipolar disorder illnesses. Our patients deserve better than that.

A lot of people think that no two psychiatrists will agree on a diagnosis, that there is no reliability, but the reality in very different. Here are some correlation co-efficients – the closer to 1.0 the number is, the more psychiatrists agree on the diagnosis. Anywhere near 0.7 is pretty damn good. Mostly ok.

Autistic Spectrum Disorder

0.69

PTSD

0.67

ADHD

0.61

Bipolar Disorder

0.56

Borderline Personality Disorder

0.54

Schizophrenia

0.46

Surely physical health problems all score 1 though? I’m afraid not. Here are the scores for a few physical conditions.

Atherosclerotic stroke

0.60

Lung cancer under a microscope

0.57

Osteoarthritis on X ray

0.51-0.68

Reflux using endoscopy

0.56

Heart attack using blood test and ECG

0.52

Smaller stroke

0.20

You see, people think that physical health is perfectly scientific, that patients fall into neat, valid little boxes, that there are tests that give yes/no answers for every condition. Anyone who tells you these things has not worked in general medicine. Sure, some patients fall easily into boxes; big heart attacks, massive strokes, overwhelming chest infections…but most patients have a collection of small problems, all in the ill/not ill grey area, which add up. This is why when our elderly relatives are admitted to hospital, the doctors tell us things like “maybe a small stroke” or “a small heart attack but we’ll treat him for an infection just in case”. It’s nonsense to say that big hearts attacks aren’t real because lots of people have small ones…we just have to be wary that illness isn’t a precise concept anywhere in medicine – psychiatry is not alone in this.

Every speciality changes its classification of illnesses every few years, as we learn more about illnesses, but only psychiatry gets abuse for doing so. How high your blood pressure has to be to be high changes every 5 minutes, we used to have bronchitis and emphysema but now we have COPD, the stages and groups of cancers changes every few years. Making categories more accurate is important and I look forward to seeing them improve with time.

Let’s be clear on another thing – psychiatry is not “growing out of control”, “medicalising normal emotions” – you only need to read the headlines about the shameful ways our services are being cut to see that. Mental health is being suffocated, and our patients with it, because it is seen as less deserving because some people are still willing to get up on stage and tell you that they don’t believe mental illness even exists.

Tonight, you have to vote whichever way you believe is best for the people who suffer from mental illness. The choice is your own, but you have to understand what voting against mental illness would mean. It would mean saying to the young woman with a BMI of 12, who thinks she is fat, that she doesn’t have a condition ­– anorexia has a 10% death rate, by the way. It would mean saying to the man who has scrubbed the skin off his hands to try to get rid of intrusive, plaguing thoughts, that he doesn’t have a disorder, just a problem with living. It would mean saying to a man whose muscles are rigid, who hasn’t eaten or drunk in days and who is mentally unconnected with the outside world, who soils himself and would die of dehydration without intensive nursing – a state I might call catatonia – you aren’t ill. It would meantelling Stephen Fry, and other public figures who have revealed their histories, that they might think they have bipolar disorder but actually it doesn’t exist; it would mean looking all your friends and family who’ve had a mental illness in the eye and telling them that their diagnoses were nonsense and they weren’t really ill, they shouldn’t have seen their doctor for that, they shouldn’t have been allowed health insurance or sick leave or medication or treatment for that, that they were just sad, obsessed, stressed or weak.

One short step away from get over it. I thought we’d moved past all that.

Thank you.

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About Alex LangfordI am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology.
I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights.
Don't mention cricket unless you've got the next fortnight free to discuss it.

55 Responses to Categorically Ill: My argument in favour of the diagnosis of mental illnesses

As some one who suffers from mental ‘illnesss’ I sometimes struggle with this concept. I mean after all surely everyone can control their mind. If only that was true and it was good to read this. Having suffered from anorexia among other things I know how deadly it can be and how little I personally felt unable to ‘turn my mind’ around and eat.

But it would be nice if some mental health workers could read this too. So many times have I been told to take responsibility for myself and you’re intelligent you can sort yourself out. You just can’t do that. In the end I get back to the point of struggling with this concept of illness. After all I’ve just been told to deal with it myself by a professional. Would I be told that by a medical doctor?

Absolutely agree which is perhaps why I struggle so much in having a mental illness (with a well researched neurological/neurobiological aspect) that many mental health professionals, particularly psychiatrists choose to believe doesn’t exist.

The problem I see, and I am not a healthcare professional so I’m sorry if I upset anyone, is that if you allow someone with ‘PTSD’ to believe that it is an illness which requires medication as the only treatment, you are taking away the opportunity for them to resolve their problems psychologically and behaviorally.
They might tell other people it is an illness and this might perpetuate avoidance and escape, which would mean the vicious circles of thought go on for ever, because socially they become to be regarded as too fragile to be honest with.
Sorry I am not making myself very clear….

Good point, but being diagnosed with any kind of illness is not a signal that you’re powerless. As another commenter said, a lot of getting better from a mental health problem is about seizing responsibility.

Absolutely agree with what you are saying, although like J above, the language mental health services use is often all about having to take responsibility for your actions, gaining insight into your condition, and spending lots of time looking for family / social factors. From what I see the social issues are usually caused by the mental illness, rather than the other way round…… Great article

Not being a healthcare professional, isn’t non reinforced exposure the treatment of choice for obsessions, rituals and compulsions? Do medications strengthen escape behaviours, providing short term relief at long term expense? Am I just being a heartless disciplinarian??!!

From my understanding of the evidence, both CBT and medication have been shown to work roughly equally well in OCD – combining them might be even better. I’m not sure medications would strengthen escape behaviours – though they wouldn’t cognitively decondition someone out of them either. Again I may be wrong but medication in OCD seems to work but cutting down on the obsessions in the first place, and the feeling of needing to perform compulsions.

From memory (which is not the best!) there were two questions asked. They meant to ask “are diagnoses valid?” but the technology failed us and they asked a different question (one they’d decided to change because it was too weighted) – “do diagnoses refelct biological reality?”. The result of this one was fairly strongly “no” – in many cases I’m inclined to agree currently!

The second question was “is diagnosis helpful?”. About 46% said “depends how it’s used” (including me) and slightly less said “no”. About 10% said straightforward “yes”, which is puzzling seeing they’d listened to some people talk about how it harmed them for an hour.

The night was taken up largely with discussing borderline personality disorder, which I find to be one of the very worst diagnoses to represent psychiatry – it’s a nasty sounding label with not much biological backing or treatment options. It was a valid point of discussion, certainly, but it would’ve also been nice to discuss other, more helpful labels like OCD or anorexia.

The partially critical reception to my position at the debate has been very different to the reaction online, which has been almost entirely positive, which is an interesting talking point.

i’d be interested in a post/blog thingy picking up and developing what you say here re. BPD and psychiatry – ‘one of the very worst diagnoses to represent psychiatry – it’s a nasty sounding label with not much biological backing or treatment options.’ i’m interested particularly in where people diagnosed with BPD ‘fit into’ the psychiatric system, especially if the system doesn’t have faith in the validity of the diagnosis or offer treatment.

and you speech reads very well! and very understandably, which is a good sign that you fully understand your subject matter.

OK I wasn’t there so if this was said with deep irony and got a laugh I apologise.

10 years ago I attended a meeting where a psychiatrist discussed his personal experience of psychosis and another psychiatrist commended him for his ‘confession’ which struck me as peculiarly offensive then too. Either mental illness is morally culpable behaviour demanding a confession, or simply an adverse life experience which people should feel free to talk about (and if they cannot the blame does not lie with the individual). But it cannot be both.

‘I listen to my patients, get to know them as individuals, hear their stories and their opinions on what they think might help – that’s why I went into psychiatry not neurology’

Errr, with respect, what do you think neurologists do? All the ones I’ve seen (a few!) have listened to me and respected my opinions on what might help. Listening and respecting patient perspectives are pretty much a baseline in effectively supporting patients living with neurological disorders since initial presentations of most neurological diseases are weird and the differential diagnosis can be wide and once you have a diagnosis you are not likely to secure much treatment adherence if you keep advocating interventions which the patient finds subjectively intolerable. You cannot refine a diagnosis or help the patient get better or stay well if you don’t listen to what is happening to them or respect their opinions. Obviously there may be rubbish neurologists out there and I have been lucky. But it is unfair to imply their practice is defined by not listening to patients or treating them as individuals.

I do agree that people misuse the idea of validity as a stick to beat psychiatry with. But isn’t your argument guilty of an ellision between the virtues of classification (some people cannot will themselves to eat even to the point of endangering their lives, if we try and identify the characteristics of this group of people this may help us understand the causes of this behaviour, how to prevent it and how to treat it – I can follow all of that) and the virtues of psychiatry. I’m not sure I spot where you explain where psychiatry alone is the discipline which can carry out the classifying, and there are psychologists waiting in the wings to explain why they could do the job differently and better…

Of course psychiatry might do the job best. As someone with experience of psychosis in the context of a neurological disorder I totally buy the idea that those darn neurotransmitters may have something to do with all this and we might want medicine to explain our mental distress.

But without explaining that bit of your argument the leap from saying to if we don’t diagnose mental illness we have to tell the person with anorexia she is ‘just sad, obsessed, stressed or weak’ is a straw man.

“Confession” was meant to describe how it sometimes feels to talk about mental illness, not as a moral judgement on what is being “confessed”.

Neurologists talk to people and get to know them, of course, but in psychiatry it is necessarily the most important task, not a corrolary to a treating a neurological phenomena. I did neurology – it’s just not the same.

Psychology and psychiatry overlap a lot. Of course both can classify – many psychologists (?most) find diagnosis useful in some way. Psychiatrists may tend towards thinking of the brain as well as the mental state, psychologists to cognitive processes – but they’re the same thing described in different ways.

As for “stressed, weak…” – it was a debate. I’m referring to how society treated people with depression/ocd/ed before mental illness became more culturally acceptable.

Is the difference between neurology and psychiatric disorders the fact that neurological disorders can be seen in the tissues under a microscope with staining or post mortem in terms of the size of certain brain parts? Psychiatric disorders cannot be seen physically, though fMRI suggests it might.
I think opponents of psychiatry are manipulating that lack of tissue proof to cut services from people who are mentally ill. These opponents are probably right wing eugenicists. They aren’t cutting neurological budgets to the same degree, but you haven’t mentioned that….but then you may not be affected.

There is no firm boundary between psychiatry and neurology. Neurology is “brain”, like movement, sensation, language and co-ordination, and psychiatry is “mind”, like thoughts thoughts feeling and behaviours.

But sometimes “mind” problems lead to “brain” sypmtoms (like in conversion disorders) and sometimes “brain” problems lead to “mind” symptoms (like in dementia).

But culturally we do tend to call things with brain changes that you can see under a microscope “neurology”, even though in every mental illness the brain will undergo changes, we just can’t see them reliably on scans. For example, in PTSD, certain parts of the brain shrink a little but become more active.

And yes, not having brain changes visible on a scan is an easy way to try to cut services.

In severe depression, a person can develop a highly negative moral evaluation of themselves, out of touch with reality even. Avoidance of social judgement would preclude recovery, but you can help that person by rooting for them, helping to modulate internal and external criticism, and intervening with social support, CBT and medication.
So I think that 1) something is morally wrong, eg. Dorsetbeing too perfectionist b) life experience is adverse so I think it is possible for someone to have to confess, but to the right ‘crime’ (a failure to understand correct discipline.) So it can be both?

I’d never make a moral judgement on a patient, like “wrong”, but I could help them recognise that they feel guilty and work with that. “Confession” could be used figuratively in this process, I’d suppose.

In the study you reference, could you clarify if the psychiatrists making the diagnosis knew the other psychiatrist’s diagnosis? The reason I ask if that if this info is known by the other psychiatrist it may bias the results.

Thanks for this post, I was interested in the debate and how it would be framed. From the outset I wish to be clear, I do not class myself as an anti-psychiatrist. Not at all. I have enormous respect for psychiatrists and have worked with many from whom I’ve learned a lot and had very positive working relationships. This post is not an attempt to undermine your profession. I also want to say that although I disagree with you at times, this does mean I do not respect you and your views, I do. You’re clearly passionate about helping people, as am I. Sadly, I think that almost has to be said as the nature of this debate often gets personal and spiteful, I have no wish nor intention of doing that. As you know I’ve been involved in this debate for some time in various forms. It is an important one and one which will continue.
I do think more weight needs to be given to what people want. Do they want a diagnosis? Can they make an informed choice? Given the potential difficulties that arise do they wish for their distress to be named? If so both yours and my views become swiftly and correctly redundant. I really think we need to stop trying to own the debate as professionals, it’s not ours to own.
My main concern with this debate is the terms of engagement (or lack of). We are in many cases having parallel arguments and arguing about, in essence, different points. If I may, I’d like to highlight your points and how I think (and it is only my view) they are misrepresenting the argument.
Your opening statement that despite campaigning some people deny mental illness exists, is an example of this. What would have been a more correct statement would have been “whilst nobody doubts or denies the impact of mental distress in a variety of forms, the concept of mental distress being an illness as like any other has been questioned”. The people from this viewpoint are not claiming that people’s distress is not real, far from it. There have been concerns regarding the approach taken by anti-stigma campaigns (which are still reporting only moderate success) and I myself tried to engage them in a discussion about this in a productive, not antagonistic way but to no avail (http://clinpsychthinking.wordpress.com/2013/10/04/mental-health-stigma-time-to-change-approach/). This is not to try to reach a high moral ground, but to try to engage people in an alternative view of mental distress and one which I and many others have found to be helpful not only clinically but can be seen in research too.
I don’t know for fact, but I’m reasonably confident that if we abandoned the use of illness, ‘Mind’, ‘Time to Change’ and others would still go about their work with just as much vigour as now.
The brain/mind link is a big jump and one which probably requires further debate, but that’s not my main aim here.
I’m unclear what the scan images are meant to be representing and I’m sure you’ll agree we need to be careful about using them and what they mean. We’re not saying that people with depression have fundamentally different brains are we?
I’m unclear though, why you suddenly suggest that the concept of mental illness “helps patients discover that they are not alone, that their suffering is not a private, unique torment, but that it has a name, and other people have been through it before. It allows them to learn about their difficulties and help themselves”. Why do you need to name it for that to happen? And what of the possibility that saying they have this illness causes them to lose hope, to become increasingly self-deprecating and to stop believing they have agency in their own life moving forwards? I often have to tell young people that they can recover, they believe they will be like this forever (often when they think it’s a chemical imbalance or similarly solely biological explanation). That cannot be useful to them surely? I know some find solace in a name and they should have that option if they so wish, far be it from me to dictate how people view themselves.
There is within this idea of naming the fallacy that one depression is like another and so on. Simply not so. The polythetic model of diagnosis creates huge variation within categories (so around 200 variants of depression for example). You can see this on twitter, people with the same diagnosis experience it very differently.
I appreciate the point that we need categories for research but let’s be honest, in all areas on mental health treatment we’re not doing brilliantly. I think we need to be careful about how and what we categorise. Is it a possibility that by
a) researching into groups of highly variable symptom clusters and labelling them as a specific entity
and
b) comparing people we see who present as one kind of the many variants within a diagnostic category
we’re actually holding research back? Whatever the ‘treatment’ is we’re looking at?
Furthermore, giving something a name is not the same as understanding it. I’ve worked with many people who are given a diagnosis who have no idea what it is. When they see their distress in the context of their life in meaningful way, which is not imposed upon them, then understanding develops.
Certain symptoms often occur together, true, but not often. What of the people who experience flashbacks without some of the other ‘required symptoms’? Would you refuse to treat them? Of course not.
The ‘are they real’ argument is again a falsehood. Again, no one is denying the distress exists it’s whether the specific, categorical entities, classed as diseases exists.
It is wrong to equate illness with validity or severity. Saying that calling it an illness protects people from being called malingerers is simply not true.
I don’t understand why we have to label all these experiences illnesses, to validate them.
Your example of migraines is a good one, no one denies they exist and we don’t deny treatment to people but I understood how real they were without thinking of them as an illness. The two are not the same.
On to reliability and this is the crux of many debates such as: diagnosis allows us to have a common language, it means people can look up useful websites, it guides treatment and we need it for research.
The figures you present are concerning. In terms of correlation coefficients less than 0.7 is moderate and many of the figures are below that.
So, experts in diagnosis show moderate agreement in what they diagnose? That is a very important point. Is it a common language? Can people look it up (they may not have PTSD/Depression as defined)? We may offer a treatment for depression (as researched) to someone who does not have it – they may not respond – then what – who takes the blame for that?
I’m by no means a statistical expert and please feel free to come back to me on that, but even showing correlation with physical problems doesn’t reassure me. Just because they get it wrong that way doesn’t mean we’re allowed to mimic their problems.
If anything, that says to me that we shouldn’t use a medical approach similar to physical illness to view psychological distress.
Mental Health services are being cut and I agree, they are seen as less deserving. So might it not be worth trying to engage the public with a different way of seeing mental distress? Of course, political factors are most powerful here and it’s quite possible that however we describe distress they’d cut services. But let’s be absolutely clear, they are not cutting services and seeing them as less deserving “because some people are willing to get up on stage and tell you mental illness doesn’t exist”. The leading paradigm, is, the illness model, perhaps it’s time to consider that.
You closing remarks, although passionate, are I think, wide of the mark. You’re equating a ‘condition’ or a ‘disorder’ with severity and functional impact. This is simply not the case.
There are many people who do not fit any diagnosis (despite DSM5’s best attempts) is their distress real? Of course. I have worked in an acute inpatient ward for 5 years. I see many people with the same diagnoses as people in community settings. What does that label tell me of their reality? Of the impact on them? Little at best.
There is also a false dichotomy promulgated in services. Mental illness and not. So Psychosis is a mental illness, but personality disorder is not. We all know that people labelled as having ‘Borderline Personality Disorder’ have high rates of completed suicide (equitable with anorexia) and nobody who’s worked with people who have difficulties sometimes labelled as such would deny the reality of their distress. Yet there had to be a paper developed called ‘Personality Disorder: No Longer a Diagnosis of Exclusion’ simply to ensure people were not excluded on the basis of a label. We cannot deny the power diagnosis has and the potential for harm.
Even within medical professions, the false dichotomy of ill and not exists, perhaps this is something holding services back? Ever heard, this is just behavioural?
Questioning the concept of mental illness is in no way ‘one step away from get over it’ and it’s disingenuous to suggest that it is.
Saying ‘their diagnoses are nonsense’ (which even staunch anti-diagnosis people wouldn’t do to someone’s face) is not the same as invalidating their distress.
I generally never say ‘it’s because you’re ill’ to people I say and yet I’m reasonably confident they feel validated and I understand them.
No-one from the ‘anti- camp’ says people with mental health difficulties should be denied health insurance. Show me someone who does say that.
Same for sick leave, people are entitled to leave for grief, yet that’s not an illness is it? Medication, if they feel it may/can help them and they are aware of the potential risks/side effects then of course take it. You shouldn’t need a diagnosis for any of that.
I would certainly never try to sum up their difficulties using ‘sad, obsessed, stressed or weak’. As much as I wouldn’t use a word such as ‘depression, borderline, OCD’.
I wouldn’t feel it was appropriate to use any single word to describe something which can dominate and destroy lives.
I can and do look people in the eye and say ‘your distress is real and I will try to help’ I have no need to label it. Giving distress a name may help some and I respect that, but not others and we need to start letting people decide how they want to see their distress and how others ought to relate to them about it.
Thanks again.

Thanks for the comment Gordon. I’m pushed for time as always so I’ll have to be somewhat shorter in my response.

Respect for you is quite mutual.

Some of your points can be addressed by noting that this was written to be one side of a debate – there are statements in there that use rhetoric devices to sell my point, though I don’t think any of them are untrue, they would have been more nuanced if the piece was written to stand alone. An example of this would be the opener, “people still don’t believe mental illness exists”.

Agree with your point regarding patient choice making the diagnosis debate redundant to the extent – services need to be shaped to accommodate this choice – i.e. not making identification with diagnosis mandatory for access to treatment – but this is fairly small problem, local PD service doesn’t force patients to agree with label, they “leave it at the door”.

I am also unsure but think Mind and Rethink are quite heavily invested in terms of the illness model – but that’s an aside.

The brain scans are simply to illustrate a point – that “mind” is not somehow disconnected from brain. Unsure by what you mean by “fundamentally different”. Everyone’s brain is different, and there’s reasonable evidence that people who suffer from many kinds of mental illness have subtle brain changes year before they get diagnosed, which aren’t amenable to the creation of a diagnostic test yet – psychotic illness is an example of this – but have tiny brain changes is no judgement on the person. In fact, gay people have tiny differences in brain structure too and I’d certainly never suggest that implied a moral judgment.

“Naming fallacy” – like a tautology – I don’t believe this is the case for a lot of mental illnesses. Like migraine, we aren’t just naming a list of symptoms but referring to a recurring pattern with an existing evidence base for causes, treatments and prognosis.

I say a name gives people hope and knowledge because I’ve heard many people tell it did so for them, in both my personal and professional lives. No, not everyone needs their problems named, but many do benefit and to stop giving names to naturally recurring clusters of symptoms to benefit this group of people, at the expense of others, when these clusters are genuine, would be peculiar.

I am sure there are many, many subgroups in each category. You note “over 200 types” of depression. I don’t know about that, but schizophrenia certainly needs better classification. But however many groups there are, “physical” medicine is still an adequate comparator – multiple sclerosis is broken down into “relapsing remitting”, “primary progressive” (etc) types, and occurs all over the nervous system. The classification is far from precise. Patient experiences will be hugely different in almost every sense. But the overall group is valid.

The dilution of research cohorts, by including very heterogeneous people, is an interesting discussion point, so I agree with you about the potential for research to be held back. A good classification is needed to further research (I compare to multiple sclerosis again) but doesn’t preclude diagnosis as useful (i.e. get rid of “multiple sclerosis” simply because it’s so hard to subclassify??).

Giving something a name can be the starting point of a framework for understand it, though again, I reiterate that is some people don’t want to use it, fine.

No, you’re right, calling something illness is not necessary to validate someone’s suffering but I believe it can be useful and should be available as an option.

Have to disagree regarding your comment that the relatively poor correlation co-efficients for physical health conditions being a reason to stop using diagnosis in mental illness. By logic you’d have to suggest dropping diagnosis in physical health, which would be absurd.

Sick leave for grief, which isn’t a diagnosis, is fine – but what would we do with people off for longer, still without a diagnosis? Who decides and how? I would worry about judgemental labels sneaking in here.

The closing remarks are rhetorical devices again, designed for a debate audience but oversold when read alone.

In summary, diagnosis should be collaborative, a choice, and the names and meaning behind the labels should be validating and supportive – but the existence of people who don’t want them, and the fact that it’s possible to get by without them sometimes, shouldn’t be reasons to fight for canning them totally.

It means approximately 10% of people diagnosed with anorexia die as a result of the medical complications or by suicide. For the sake of ease of discussion in the debate I took a composite of research figures as results varied. Here are two papers that demonstrate this.

My diagnosis have been recurrent major depression, clinical anxiety and….bring on drum roll…..borderline personality disorder (oh no! gasps crowd…oh God! groans mental health people.) Yes, yours truly has been the mother of all anathema (that’s the worst thing imaginable by the way, a person with absolutely NO integrity.)
Well, its supposed to be…..but really I am just a manifold collection of behaviours, not an imagined thing or my diagnoser’s shadow. It is obvious that in practical usage, BPD sufferers experience projection of all that is negative onto them. Not being a psychologist, I am unable to break through their ego defences to point out this reality, but as some of them can barely read or write I think that pointing out basic facts may be an uphill task.
I do wholeheartedly agree with Alex SHO that diagnosis is valid; I think an additional diagnosis of Anathemising Projection Conduct Disorder APCD could be added!!!!;)

The ‘problem’ with MH diagnoses is that the medical model of psychiatry is constantly trying to fit people in to categories that often pathologises what are on fact ordinary experiences. So if my cultural background is that the spirits of my ancestors come visit me and that I am invested with prophetic powers even if I cause no harm and am not distressed Psychiatry sees this as pathological or the start of something pathological.

Simply because you as a Psychiatrist do not hear voices/see things/get messages doesn’t mean that this must be abnormal. You are simply imposing your cultural values on my ( or anyone elses) experiences because it doesn’t fit your model of the ‘healthy’ world.

So if we move from that starting point and then consider actual mental distress then instead of a reductionist medical model that is clinician focused apply the social model used in disability fields- after all you accept that the severe conditions are disabling. So what disables people? Well, as a start, MH services response to distress. Instead of seeing the individual as the problem then refocus and see what social barriers face vulnerable people and change these.

Then consider how disordered the response of MH services can be towards an individual’s distress. You will find very few service users who cannot describe a traumatising experience at the hands of the services meant to ‘help’ them. Look at the behaviour of your team, your service and consider what dysfunctional diagnosis fits best. Far too easy ( and professionally lazy) to say MH professional’s dysfunctions are simply reflecting patterns of behaviour of their clients! Why not the other way around?

As it has been brought up lets look at BPD as an example – a diagnosis don’t forget invented by male psychiatrists to describe ‘neurotic’ drama queen women who opposed authority. Stiil part of the diagnostic criteria isn’t it – challenging behaviour albeit of a different order- in this area of north London almost every single woman has a BPD diagnosis.

As far as stigma goes this will remain the big one. It is a dump diagnosis of blame. Blame the victim (often of serious abuse), tell them they have to take responsibility for all their behaviours ( thus automatically ignoring all other serious distressors such as command hallucinations) and claim that they are the group that are manipulative and therefore take up so many resources.

Of course as Psychiatrists you could instead treat the symptoms of trauma without blaming the victim – how about the starting position being abuse of children and women is the dysfunction and the response to this is not?

There are not many women who will think that attempting suicide or self harm to get you through the trauma of rape is a disproportionate response to the unresolved trauma experienced. For Psychiatry to then pathologise such coping mechanisms on the basis that her personality must be ‘disordered’ could be considered in some circles as a typical male response to female rape . By continuing to use this as a diagnosis Psychiatry and all the MH professions that follow it collude with society’s turn a blind eye attitude. In years to come you will look back in shame on this -as you did when the DSM stiil had homosexuality as a mental disorder ( any gay male psychiatrists dx pts with BPD take note!)

When all the above has been addressed and what is left is disordered distressed behaviour and feelings then think with your patient what will actually help – at the time, during and after. That works with ‘psychosis’ as well whatever your books tell you.

Listen to what is being said and treat the distress. Dont try fit it in to a tick box. Clustering simply turns people in to currency – it has very little to do with patient experience. And for those MH clinicians reading this and thinking ‘yes but we know our patients and have years of observation etc etc’ let me remind you: Every single MH pt knows your questions, the answers they are meant to give (even if they can’t) and how to ‘play the game’. Even if they then don’t! If you have a window on 10% of your patient’s lives you will be lucky.

Psychiatry does would not consider someone who thought spirits came to visit them, where this was part of their cultural background to have a mental illness. In fact, a delusion, where you have an unwavering belief in something that is not true, has to be out of keeping with your social and cultural background and surroundings, to be considered a delusion. Also, in order to be considered part of an illness, a persons experiences or symptoms have to be something that distresses them, or negatively impacts on their life in some way to be considered part of an illness. E.g. An athiest psychiatrist would not think someone with an unusual spiritual or religious belief was having a delusion, if it was something a group of people believed.

“There are not many women who will think that attempting suicide or self harm to get you through the trauma of rape is a disproportionate response to the unresolved trauma experienced” – evidence of this claim?

What sort of evidence do you require for this? Presume that you don’t think that it is only scientific based empirical ‘evidence’ that counts.The sort that has value in the world of medicine but has little value or relevance to victims, their family, their friends. Unresolved trauma is that – unresolved.It narrows down your coping mechanisms, intensifies your emotional responses.

Ask any group of women – survivor of rape or not- if they can imagine how they would manage this.Ask directly if they could imagine wanting to die at any point rather than face the shame and stigma. Ask them how they think they would cope if they felt they could not speak up or spoke up and felt dismissed. Ask them their responses to the reports of rape and abuse victims committing suicide during/after trials . Consider that the Met Police have a rape conviction rate of 7% (their stats)

I have not met many women who have not thought that they would consider suicide at some point in these circumstances – even fleetingly. Many women know others who have or do self harm as girls or as adults because of sexual assault and understand exactly why.

Where they can women and girls talk, confide, share. But with researchers for the sake of empirical research? Not many as it retriggers the trauma and adds to the distress.

If you want research go to the Home Office website, to Rape Crisis research, to the Stern report, etc etc etc. It is greatly under reported and therefore under researched and I have no idea whether victim case studies and anecdotal evidence counts as evidence in the way you are seeking.

If something is not researched it does not mean that it does not happen. In this case any paucity of research data is much more likely to be a reflection of how little value psychiatry places on the victims own interpretation of their experience (and the factual situation) .

If more money and support went in to treating victims say as PTSD patients then you may get the type of ‘evidence’ I think you may be seeking. However for now Psychiatrists prefer to pathologise and give a BPD dx instead.

Think Kierkegaard was spot on. Maybe the entire DSM can be replaced with this one statement and Psychiatry can start over.

I often reflect on intention – usually in the context of harm caused. Clumsy action or words with good intention I can move on from.Intention to cause harm or knowingly setting off a chain of events that you know will cause harm I have more problems with.

Psychiatrists giving diagnoses when they know the stigma and potential for harm falls in to the second category for me. The rush to fit someone in to a category, a set of parameters that are artificial constructs is not a person centred approach. It is a system designed to give framework for psychiatrists to at best allay their own anxieties and at worst exert power. I wont get in to the ‘why have we adopted a system driven by an insurance based medical system’ argument here!

And of course now we have a Payment by Results (PBR) based system so that all patients have to be clustered and the MH Trusts are then paid an amount on a per capita calculation according to diagnosis. So Psychosis and PD = higher payments as seen as needing high input. PTSD and Anxiety related disorders = less funding.

Now while I am sure the scientists among you would make the argument that these groups DO require more input as after all scientific based empirical research has shown this. But it is a circular argument or even non argument. If for eg Psychiatrists had moved from diagnosing PD to PTSD in all forms then this group would then show as needing the highest input. Except they didnt and they dont and to rediagnose now means that the DH then will cut the funding for the Trust to provide MH services. As that is what the formula dictates .

The RCPsych supported PBR knowing this so you have question why there is such support for continuing to to ‘diagnose’ instead of responding to the distress even when it doesnt neatly fit in to a funding box. Because that is what the DSM diagnoses and cluster tick boxes have become – a funding stream with patients as the currency.

If this system worked then maybe I and others wouldnt feel so strongly about the iniquities of this. But it doesnt. A diagnosis, a label certainly does help some people to contain and manage high levels of distress. But is that driven by the need to explain to other people, do we think that this works on a long term basis or just as a necessary holding mechanism? It is not the only approach that could be used. It is the one that has been legitimised. And often without realising it patients are drawn in to a life of significant stigma and discrimination and loss of autonomy because that is all they have been offered.

And like I say the system is not working. Look at crisis care – in this area up to 30% of people assessed under the MHA are known to services but have ‘no team’ ( for the ‘evidence’ readers this is the figures given by the MH Trust/ LA annual report of the Mental Health Law Group which oversees MHA actions). And given on ave 80% of those assessed are detained work out the rebound figure.

All these people have diagnoses – and still they are at a level of distress and risk that results in being locked up – or worse. Again this area has amongst the highest rate of suicide for men and women in the country of people KNOWN to MH services.

So tell me how the absolute reliance on diagnoses, to the point of excluding all other approaches, supports those in severe mental distress ? Psychiatrist are Doctors. I believe the hippocratic oath gives mention of ‘do no harm’. A rush to diagnose to meet your own needs, the services needs, MH workers needs does not automatically equate to meeting patients needs

A person who has been punished is not thereby less likely to behave in a given way; at best he learns how to avoid punishment. (Skinner.)

I think a lot of problems relate to the ignorance of how people learn. Using a diagnosis as a punishment (labelling or stigmatising) does not help.the patient learn to recover, nor does it create job satisfaction for the professional because they feel less powerful and ineffective. Cynicism and vengeance on behalf of the professional towards the patient is a natural consequence of lacking training, and is far from rare.

The reason the outcome is so poor with those diagnosed/labelled with BPD is that the contingencies of reinforcement in the environment are reinforcing bad attempts at controlling emotional distress, and not helping with genuine, deeply courageous attempts to be effective. There is a definite pattern here. Psychiatrists have shunned ‘BPD patient’s, partly because their time is rationed, and the behaviour patterns complex, but also because they generally have not experienced the conditioning environments themselves, and also they cannot control what influences or reinforcements lay in the environment. You can’t control who someone associates with or how they relate.
However it is wrong to put a ‘flawed start’ at the bottom of patients or PEOPLE, as I like to call them. Much of the research that underpins modern psychiatric diagnosis was undertaken by Emile Kraeplin who was a believer in eugenics, the improvement of the human race by excluding what he thought of as degenerate genes, or PEOPLE. The question is whether his research reflects his belief in eugenics, rather than in helping people in distress. His unwarranted pessimism in ‘dementia praecox’ suggests that his research was flawed, distorted by his ambition to start a eugenics programme.
I suggest also, that the postulation of a rotten Apple in BPD is also flawed, and that the whole process of ultimate ends in flawed. Million writes elegantly on BPD, using a small thesaurus, but ultimately it is an exercise in artificialality. Only when psychiatry recognises and addresses the abuse of power involved in eugenics can it show diagnosis in a wholly positive light.

Just flicked through Szaz on wikipedia. Ideas seem.dated (not that I know what I am talking about), but the potential for patients with anxiety to become clients for doctors selling drug treatments and reinforcing harmful behaviours is interesting. Is there marketing for cures for misery? Could this create more severe depression when the patient has not been encouraged to mobilize his own coping skills (which he/she doesn’t know/believe he has). I don’t know the answer………Could the thrust of his argument be that doctors are interfering with beneficial adaptation?

Can I just say what a relief to uncover someone
that actually knows what they’re talking about on the internet.
You actually know how to bring an issue to light and make it important.
More and more people really need to check this out and understand this side of the story.
I was surprised that you aren’t more popular given that
you surely have the gift.

Hi, it was very refreshing to come across your blog and I agree that diagnosis is imperative for someone who is very ill with a mental illness. It should be given sensitively and in a language that is easily understood with plenty of support. My adolescent daughter has been in an adolescent inpatient unit for most of the last 2 years and diagnosed with Bipolar Disorder and it is proving very difficult to treat. Prior to this admission a CAMHS psychiatrist said a diagnosis was unimportant and believed she was just bored and this almost killed her as he refused to consider that she may indeed be very ill and only gave her psychotherapy which made her much worse. I feel that psychiatry as it is at the moment needs a major overhaul with more thought given to patients rather than the psychiatrists and their professional pride. I have found my family’s experience of psychiatry to be awful in the extreme and am left wondering how ill people get the help they need without loved ones having to force the issue.

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I am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology.
I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights.
Don't mention cricket unless you've got the next fortnight free to discuss it.